E-ISSN:2456-3110

Case Report

Management of Osteomyelitis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 4 April
Publisherwww.maharshicharaka.in

Successful management of Osteomyelitis through Integrated Approach : A Case Report

Memane N1*, Memane S2, Gupta G3
DOI:10.21760/jaims.9.4.53

1* Nanasaheb Memane, Head of Ayurveda Department Consultants Ayurveda, Department of Ayurveda, Bhakti Vedanta Hospital and Research Institute, Thane Mumbai, Maharashtra, India.

2 Sonal Memane, Consultants Ayurveda, Department of Ayurveda, Bhakti Vedanta Hospital and Research Institute, Thane Mumbai, Maharashtra, India.

3 Gayatri Gupta, Clinical Research Coordinator, Department of Medical Research, Bhakti Vedanta Hospital and Research Institute Mira Road, Thane Mumbai, Maharashtra, India.

Osteomyelitis is a severe condition characterized by the infection and inflammation of the bone and its bone marrow, thus quickly impacting the Harversian systems. It is often caused by bacteria, the methicillin-resistant S. aureus bacteria being the most common organism. Conventional treatment typically involves long-term antibiotic therapy, surgical debridement, and supportive measures. However, the increasing prevalence of antibiotic resistance and the adverse effects emphasize the need for complementary and alternative treatment approaches. The rationale for Ayurvedic is that inflammatory swelling is correlated with vidradhi. This case report discusses about the chronic inflammation of osteomyelitis caused by fracture of the humerus with mal-union which has been treated successfully through an Ayurvedic approach by administering Varunaadi Gana Kashaya (decoction), Nyagrodhadi Gana Kashaya (decoction), Arogyavardhini Vati (tablet), Lakshadi Guggulu (tablets), Local application of Jatyadi Taila (oil). Results: The patient was followed up every 7 days while on ayurvedic treatment. In the initial days, the wound was closed with a cast; after 10 days, the cast was removed, and discharge was drastically reduced culminating in overall wound healing. Conclusion: This case report highlights the successful management of osteomyelitis using Ayurvedic medicine as an adjunct therapy. The individualized Ayurvedic treatment plan, including internal medicine, external applications, and lifestyle modifications, contributed to symptom improvement, reduced inflammation, and promoted healing in the patient.

Keywords: Abhyantar Vidradhi, Asthi-Majja Vidradhi, Nidan Parivarjan, Chronic Osteomyelitis, MRSA

Corresponding Author How to Cite this Article To Browse
Nanasaheb Memane, Head of Ayurveda Department Consultants Ayurveda, Department of Ayurveda, Bhakti Vedanta Hospital and Research Institute, Thane Mumbai, Maharashtra, India.
Email: 		Memane N, Memane S, Gupta G, Successful management of Osteomyelitis through Integrated Approach : A Case Report. J Ayu Int Med Sci. 2024;9(4):316-321.
Available From
https://jaims.in/jaims/article/view/3259

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-02-13 2024-02-23 2024-03-04 2024-03-14 2024-03-19
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 22.20

© 2024by Memane N, Memane S, Gupta Gand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Nanasaheb Memane et al. Management of Osteomyelitis through Integrated Approach

Introduction

Osteomyelitis is a severe condition characterized by the infection and inflammation of the bone and its bone marrow, thus quickly impacting the Harversian systems. A persistent, severe, and sometimes fatal infection of the bone and bone marrow is called chronic osteomyelitis. It is often caused by bacteria, the methicillin-resistant S. aureus bacteria being the most common organism, fungi, or, less commonly, viruses. Conventional treatment typically involves long-term antibiotic therapy, surgical debridement, and supportive measures. It is a frequently recurring condition, as it is difficult to cure definitively after inadequate treatment of acute osteomyelitis.[1] However, the increasing prevalence of antibiotic resistance and the potential for adverse effects emphasize the need for complementary and alternative treatment approaches. Long bone osteomyelitis may occur as a result of hematogenous bacterial dissemination from another part of the body, as shown in children, or secondary to trauma following compound wounds, as observed in adults. The treatment for osteomyelitis affecting the humerus differs from that for osteomyelitis involving the tibia and femur, having an overall incidence of 3.4%.[2]

Ayurveda, the ancient Indian system of medicine, provides a comprehensive approach to healthcare. Ayurvedic principles focus on individualized treatments to restore balance and harmony within the body. The use of herbal, authentic Ayurvedic formulations, external applications, and lifestyle modifications can aid in improving symptoms, reducing inflammation, and promoting healing. While Ayurvedic interventions have evidences for therapeutic role in various infectious conditions, their efficacy in osteomyelitis management is yet to be fully explored. The rationale for Ayurvedic treatment is that inflammatory swelling is correlated with vidradhi.[3] It is a disorder that results in one or more swellings, either internal or external, caused by vitiation of the skin, blood, muscle, fat tissue, bone, ligament, and tendon.[4] The painful condition known as Bahyavidradhi also called an external abscess, has all the characteristics of inflammation and a tendency towards suppuration.[5] The Ama (unripe stage), Pachyamana (ripening stage), and Pakva (ripened stage) resemble those of Sopha (inflammatory edema). Conservative management of Vidradhi involves the use of both

external and internal treatments to prevent inflammation of the edema, as indicated by Sopha Chikitsa in Ayurveda.[6] By Varanachikitsa, appropriate surgical operations such as incision, drainage, etc., are carried out if the situation progresses toward suppurative alterations and are explained as “Antarvidradhi (Asthividradhi)-Naadivrana" by Sushrut Samhita in Vidradhi Nidan Chapter 9.[7] Ayurvedic treatment in such conditions is good alternative to surgical management. Conservative management also avoids complications that can arise post-surgery and decreases hospital visits. This is a case that has been successfully managed conservatively, based on Ayurveda principles.

Case History

A 38 years female patient referred to the Ayurveda Department of Bhaktivedanta Hospital and Research Institute by the orthopedic doctor with complaints of localized pain at the fracture site, loss of strength in the hand, sinus developed at site and pus discharge from the wound, on-and-off fever, loss of appetite, malaise. History shows a compound fracture of the right humerus 4 years back. The orthopedic surgeon operated the patient four times over a period of one year and then referred the patient to Ayurvedic practitioner in view of failed desired surgical outcome of fractured segments, but the symptoms remained the same. Pus culture sensitivity showed MRSA and antibiotic courses such as injection vancomycin for 4-6 weeks were administered as per the sensitivity. However, the patient did not show any response, and pus discharge was continued without any sign of healing. An Ayurveda surgeon conducted a thorough assessment, and strict diet and lifestyle advice was given to the patient.

Hetu (Causative factor)

1. Fracture and mal-union

2. Sankramanajanya (polymicrobial infection: Staphylococcus aureus, Streptococcus pneumonia)

3. Malabadhata (constipation)

4. Agantuja (external cause) such as Aharaja (dietary) or Vishamashana (irregular food habits with excessive intake of pungent and sour, i.e., abnormal and excessive intake of curd, etc.)

5. Arajaska


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(irregular menses) every 6 months for 5 years

Astavidha Parikshan (Clinical examination)[8]

Nadi (Pulse) - Sarpagati Saam, Guru Sanipatik.

Mutra (Urine) - Avila Varna (normal)

Malam (Stool) - Malabadhata (constipation)

Jihwa (Tongue) - Anupalepa (clear)

Shabda (Speech) - Samanya (normal)

Sparsha (Touch) - Ushna

Drik (Eye) - Samanya (normal)

Akriti (Shape) - Sthula (obese)

Prakruti - Vata Pitta Prakruti constitution.

Pathophysiology[9][10]

  • Hetu Sevan - Abhishyandi Aharaja
  • Dosha - Kapha Pitta Pradhana Tridoshaja
  • Dushya - Rakta (blood), Kandara (tendons and ligaments), Asthi (bone), Majja (bone marrow), Tvak (skin).
  • Dosha Adhisthan - Asthi (bone)
  • Agni - Jatharagnijanya (central digestive systems), Dhatvagnijanya (nourishment and metabolism of tissues)
  • Strotas - Rasa, Rakta, Asthi, Majjavaha, Mansavaha, Purishavaha
  • Strotodusti - Sanga, Vimargamanam
  • Udbhavastana - Amashaya (Kapha, Pitta), Pakvashaya (Vata)
  • Adhisthan - The Adhisthana was Asthi and Majja with Vata-Pitta- Kapha
  • Roga Marga - Madhyama and Shakhagata
  • Vyadhi Swabhav - Chirkala (chronic).

Management and Treatment

Treatment of Osteomyelitis comprises of Aama Pachan and Dosha Nirharan.

Internal Medication

1. Varunaadi Gana Kashaya (decoction) ingestion 1 tsf powder with 200 ml water, boil water upto half, drink after filtration in the morning for 15 days x 3 months[11]

2. Nyagrodhadi Gana Kashaya

(decoction) twice after food x 3 months[12]

3. Arogyavardhini vati (tablet) x 42 days[13]

4. Lakshadi Guggulu (tablet) 1 BD x 3 months[14]

5. Naadivranakarma (Local application of Jatyadi Taila oil) for local medical debridement and healing. (Sushruta Nadivranchikitsa chapter)[15]

Aushadi (medicine)Matra Avam Kala (dosage)Anupanam (titration)
Varunaadi Gana Kashaya (decoction)1 tsp powder x OD x 3 monthsboil with 200 ml water upto half f/b filtered
Nyagrodhadi Gana Kashaya (decoction)1 tsp powder x BD x 3 monthsboil with 200 ml water upto half f/b filtered
Arogyavardhini vati (tablet)1 BD x 42 days100ml of lukewarm water
Lakshadi Guggulu (tablet)1 BD x 3 months100ml of lukewarm water
Jatyadi Taila (oil)Till wound healingLA

Lifestyle modifications

1. Aharaja (dietary) - Daily wheat or jawar roti or multigrain bhakri, only have moong dal (lentils), all vegetables except tomato, brinjal, potato, and sweet potato.

2. Fruits - Fig, Raisin, chickoo, musk melon, pomegranate.

3. Vihar (lifestyle) - Anulom Vilom Pranayama for normal Doshagati.

4. Sleep early, eat on time, balanced diet (Samyak Aharaj).

5. Avoids - Curd, perished food, fermented, stale, fried, beans, late night sleep, sex, late food, rice, daytime sleep after food, anger, excessive chilly, Non-Veg.

After administering the above-mentioned Ayurveda treatment along with diet and lifestyle changes, the patient was followed up every 7 days. In the initial days, the wound was closed with a cast; after 10 days, the cast was removed, and discharge was drastically reduced. The doctor also advised continuing Ayurveda medicines. The next follow-up local application medicine was prescribed. The patient's general condition was improved, with better bowel habits, improved appetite, improved sleep, a lighter feeling in the whole body, and reduced pain at the site of the wound.


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After a month follow-up, the patient had no discharge, and an X-ray clearly did not show any sinuses, and the wound had dried completely. A bone segment was completely healed after starting Ayurveda treatment.

SymptomsBefore treatments2 months after treatments3 months after treatments
Continuous pain at the fracture site
loss of strength in hand
Fever persistence
loss of appetite (Aaruchi)
Malaise
Sinus developed at the site (naadivrana)
Pus discharge at site.
Constipation		3+
3+
persistence
3+
Severe
4+
4+
present		1+
1+
On and off
1+
Moderate
1+
1+
No		Absent
Absent
Absent
Absent
Mild
Absent
Absent
No

Discussion

If the condition of Aama (inflammation) is present, then the remedy should be Shophahara, and Raktavsechankriya (bloodletting) has to be carried out, i.e., Shaman Chikitsa, or palliative treatment. When it reaches the Pakwa stage (ripening), it has to be treated like a Vrana. Here, Aama has been created by the daily intake of curd.[16]

Properties of curd

Curds have properties of moisture, are unctuous, and hot in potency. Thus, daily intake of curd increases moisture in the tissue and aggravates Kapha and Medhas (fat). Although curd is mentioned in Ayurveda having many medicinal properties but in certain personalities (Prakruti), and Kala (time) that is night time acts as Raktadoshavardhak (blood enhancer). This abnormal and excessive intake of curd creates Aama (inflammation) and thus Shaman Chikitsa or palliative treatment has been advised.[17] As there was no satisfactory clinical outcome with conventionally available standard treatment, Ayurveda treatment approach evidence better clinical outcome. Just by using different pathophysiological approach enable the doctor to diagnose the condition and changes the prognosis of the disease. With proper diet and lifestyle balance of Doshas, Dhatu, and Mala was established, vitiation of Doshas was checked with internal medication, and afterward

local application. As there are Rakta, Vata, Kapha, and Pitta Dushti (vitiation) in the internal abscess, there are 60 ways mentioned by Sushrutacharya for Vranachikitsa.[18] Ayurveda Samhita's elaborately states the principles of treatment to purify the blood and balances the vitiated Vata, Pitta, and Kapha by including a layered treatment pattern. i.e.

1. Aahar (Subjective Diet pattern)

2. Vihar (tailor made Life style pattern)

3. Aushadh - Medicine and Surgery

Ayurveda has a holistic approach to treat the diseases. The role of Physical, emotional, and Spiritual health in building immunity is a crucial factor as per Ayurveda science. This principle of increasing immunity is the unique gift of Ayurveda science to the world of Medicine.

Patient treatment is a stepwise treatment as mentioned below

Nidan Parivarjan (removal of cause) - Hetusevan i.e., Identification of long-standing and triggering causes (Sannikrishta and Viprakushta) is the first step, stopping the cause itself stops further progress of the disease.

Doshanirharan / Prashamanam (detoxification) - Eliminating or correcting the vitiated Doshas with the help of medicinal treatment with necessary ancient surgical techniques such as debridement (Vran Shuddhi), cleaning the wound, eliminating dead space, enhancing revascularization (Rohan Kriya) of nearby soft tissues, improving wound protection and minimize vascular insufficiency with proper drain. It increases structural stability through the application of Dhatuposhaka Chikitsa (Asthi, Majja, Rasa, and Raktadhatu). By removing the impurities of Rakta Dahtu and decreasing Strotorodha, it reduces bacterial infections, eliminates dead necrotic tissues, and improves blood circulation, nutrition, and the production of good granulation tissue (which resolves in the bone cavity with bone healing).[19] Every medication used can treat all Vidradhi manifestations by penetrating the biofilms linked to the refractory nature of chronic osteomyelitis such as Lakshadi Guggulu Vati has properties of repair which triggered on the necrotic bone such as osteoclasts, osteoblasts, histiocytes, and vascular elements. The Vatakaphahar property helps with the regression of inflammation,


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prevents further necrosis, reduces ischemia, and is indirectly helpful for bone rejuvenation.[20]

Apunarbhav Chikitsa (Non Recurrence) - Preventing the recurrence or further progress of disease with the help of Rasayan Chikitsa. This principle enables one to improve immunity.[21]

Conclusion

This case report highlights the successful management of osteomyelitis using Ayurvedic medicine as an adjunct therapy. The individualized Ayurvedic treatment plan, including internal medicine, external applications, and lifestyle modifications, contributed to symptom improvement, reduced inflammation, and promoted healing in the patient. Further research and clinical studies are warranted to validate the efficacy and safety of Ayurvedic interventions in the management of osteomyelitis and to determine the optimal combination of conventional and Ayurvedic therapies for this condition. The step taken by the Indian government in 2017-18 as an integrated medicine policy for the Indian healthcare system is very appropriate in pursuit of our discussion and findings. Ayurveda and Allopathy can go a hand in a hand as an integrated medicine for patients to benefit from almost all complicated and non-complicated diseases for cure and non-recurrence.

References

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